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Heart Failure

Almost never do clients tell me any member of their family passed of heart failure when sharing their family history. More often I am told their passing was from "old age" or maybe they had high blood pressure or even bypass surgery, but heart failure is not well understood or even familiar to most although it is becoming more common in adults older than 65 years of age largely because treatment following a heart attack is more and more effective, as is the treatment of valvular disease and hypertension (King, Kingery, & Caseky, 2012).



Heart failure clients experience difficulty breathing, #fatigue, and signs of fluid overload, which may include #edema in their legs or even their lungs. There is no single diagnostic test for heart failure; rather, this is more a clinical picture the practitioner discerns after gathering data from their history, providing a physical exam, and obtaining laboratory and diagnostic tests. The diagnosis in itself is complex, involving a number of structural and functional cardiac disorders but ultimately the ventricles in the heart fail to function optimally which results in fluid overload.


Elevated blood pressure and valvular heart disease are the major risk factors for heart failure. Diabetes mellitus is yet another, increasing the risk of heart failure by twofold. Smoking, physical inactivity, obesity, lower socioeconomic status are also risks. The heart muscle simply gets weak and can't push blood out of the heart as effectively, so it backs up in the lower extremities, sometimes the lungs and even abdomen.


Findings Suggestive of Heart Failure


Individuals with heart failure struggle when they try to do anything strenuous. At first this may be exercise, but then it is more noticeable with normal daily activity. This leads to fatigue and overall weakness, not being able to walk to the mailbox or getting winded when changing clothes. When the clinician listens to the heart of someone with heart failure, they may hear a third heart sound which is indicative of changes in the heart in effort to compensate. The heart sounds in the chest may also move a smidge in their location, and these two findings are especially effective at identifying heart failure, but they aren't especially common either.


Distended veins in the neck can be seen sometimes, and rales in the lungs can be heard many times, but pitting edema in the legs is quite common. Heart murmurs are often heard as well, although not terribly helpful in itself, in making diagnosis. Laboratory can be helpful and help the clinician discern if the cause of heart failure is reversible. The BNP is helpful in evaluating those who are struggling to breath and the underlying cause is thought to be heart failure. BNP is secreted by the atria and ventricles in response to stretching or increased wall tension. These normally increase with age and are higher in women and blacks, and can be elevated in those with renal failure, but they are fairly reliable for making diagnosis, particularly in ruling out diagnosis. The average cutoff levels for heart failure were a BNP level of 95 pg/mL or a N-terminal pro-BNP level of 642 pg/mL.


BNP levels are strong predictors of mortality at two and three months, as well as cardiovascular events into the future, especially when rates are greater than 200 pg/mL or N-terminal pro-BNP level is greater than 5,180 pg/mL. A 30 to 50 percent reduction in BNP level while admitted to the hospital shows improved survival rate and reduces rehospitalization, and when outpatient, optimal target is about 100 pg/mL and the N-terminal pro-BNP less than 1,700 pg/mL.


The chest x-ray is really one of the first diagnostic tests when ruling out heart failure because it can identify pulmonary causes of dyspnea. Heart failure is a potential, but so might pneumonia, pneumothorax, or a mass of some sort. It's important to identify the difference here, but when there is fluid in the lungs and edema in the legs or elsewhere, along with difficulty breathing, then the diagnosis of heart failure is more likely. Pleural effusion and cardiomeagaly are other potential findings that slightly increase the likelihood of heart failure diagnosis.


Electrocardiography (ECG) is another tool useful in understanding the client who presents in fluid overload. The clinician may identify what is called "left bundle branch block, left ventricular hypertrophy, acute or previous myocardial infarction, or atrial fibrillation," and this may indicate need for echocardiogram, stress testing, or cardiology consultation. Normal findings or minor abnormalities on ECG make systolic heart failure only slightly less likely.


Diagnosing heart failure is complex and while there are published diagnostic criteria, this really is a clinical diagnosis. Major findings are pulmonary edema, enlarged heart, neck vein distention, orthopnea, rales, third heart sound gallop, and more minor findings are ankle edema, dyspnea on exertion, coughing at night, higher heart rate, and enlarged liver.


References

King, M., Kingery, J., Casey, B. (2012). Diagnosis and evaluation of heart failure. American Family Physicians, 85(12), 1161-1168.

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